Pinpoint precision

Steve Segal was the first person to undergo Sunnybrook's new minimally invasive mitral valve program.

Doug Nicholson. Not to be printed, broadcast or transmitted without the permission of MediaSource or its representatives.

by Alexis Dobranowski

March 26, 2017October 3, 2011

A faulty mitral valve had been keeping Steve off the greens, until a team from Sunnybrook repaired that valve using a leading-edge minimally invasive mitral valve repair procedure.

Doctors had been monitoring 58-year-old Steve's leaky mitral valve for over 20 years.

A faulty mitral valve means the flaps of the heart's one-way mitral valve don't close properly and leak, causing blood to flow backward into the left atrium. This means decreased blood flow to the body, placing extra burden on the left ventricle and the lungs.

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As Steve's leak worsened, so did his energy level. He wasn't able to "leap tall buildings," he jokes.

But in seriousness, Steve says, the leak did affect his day-to-day life: he suffered extreme fatigue, couldn't walk long distances, couldn't take the stairs and had frequent headaches.

Then Steve heard of a brand new procedure used by Sunnybrook's team of experts, made up of surgeons and cardiologists, who can repair faulty mitral valves without open-heart surgery.

In April 2011, Steve was the first patient at Sunnybrook to undergo the state-of-the-art percutaneous – where access to inner organs is gained via needle-puncture of the skin, rather than by cutting the patient open – mitral valve repair procedure. Sunnybrook is now one of just two centres in Canada offering it.

During this ultrasound-assisted procedure, a small catheter is delivered to the heart through a blood vessel in the leg. The surgeon then carefully clips the faulty flaps of the mitral valve back together. The heart continues to beat normally during the procedure, which takes only about 75 minutes.

"I was out of the hospital in a day, and it might have been even sooner if I wasn't the first patient," Steve says. "I'm walking up stairs now. I'm riding the exercise bike."

While surgeons have been repairing leaky mitral valves for years by splitting open the breast bone, this new clipping procedure means faster recovery with fewer complications, says Dr. Gideon Cohen, cardiovascular surgeon. To date, a third of all patients who need mitral valve repair haven't been treated because they are not physically able to withstand conventional open-heart surgery. It's simply too high risk.

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"The results with this mitral clip procedure have been truly remarkable," he says. "Patients have enjoyed shorter hospital stays, less pain and an earlier return to normal activities."

As someone who had open-heart surgery to fix a nearly ruptured aorta eight years ago, Steve saw immediately the benefits of the minimally invasive mitral clip procedure. He says there's simply no comparison.

"I was in the hospital for over a month after my surgery in 2004," he says. "With the clips, you aren't exposed to the trauma of surgery, the insult to the body. There's less chance of infection because you aren't opened up."

And the best part: he got to recuperate at home in the care – and cooking, he laughs – of his wife and two children.

The mitral clip procedure is the latest in a series of minimally invasive procedures being pioneered at the Schulich Heart Centre. From beating heart bypass, to replacing faulty aortic valves through an opening the size of a fingernail, Schulich's team of expert cardiologists, cardiac surgeons, vascular surgeons and cardiac anesthetists are working together to come up with the most innovative ways to treat the heart and damaged blood vessels.

It was just 50 years ago that open-heart procedures were becoming popular. And now, surgeons and cardiologists are trying to find more and more ways to do procedures without opening patients up at all.

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"It's a huge deal – cutting someone's chest open, putting them on a heart-lung machine, keeping them in hospital to try to recover," Schulich Heart Centre Chief Dr. Strauss says. "Clearly that is very invasive."

Schulich's experts have been at the forefront of designing and implementing new less invasive options. In Sunnybrook's Arrhythmia Invasive Suite, for example, surgeons don't even invade the patient's personal space.

"What's really unique when you are watching the procedure is that the doctor isn't even in the room," Dr. Strauss says. "They are all sitting in a room next door and it looks like they are playing computer games. That's pretty minimally invasive."

It's stereotaxis, a way of locating where a surgeon needs to be in the heart by the use of these magnets that are beside the patient.

"It gives you a 3D map of where you are in terms of placing the catheters," Dr. Strauss says. "Our experts have really been taking the lead on this."

Dr. Strauss says as leader of the Schulich Heart Centre, he strives for innovation and wants to maintain a cutting-edge program that embraces new technology.

"And then, of course, bring it all to patients."

Transcatheter Aortic Valve Implantation

When Ron Armstrong travelled to Buffalo, New York last winter to catch a few games in the World Junior Hockey Championships, he dreaded each final buzzer. And not because of anything that was happening on the ice.

"I didn't want to have to go outside," he recalls. "It was so hard to walk and move around."

Ron, 77, had a long history of heart problems and had undergone two open-heart bypasses, one in 1975 and another in 1996.

When he began having chest pains and difficulty breathing last year, he thought it was angina again. Instead, his aortic valve was deteriorating.

Narrowing of the aortic valve, or stenosis, occurs when the aortic valve, which keeps oxygen-rich blood flowing from the heart into the largest artery in the body, becomes blocked, impairing flow of blood to the rest of the body.

"These patients experience bad chest pains, profound fainting attacks, significant shortness of breath, leading all the way to heart failure," says Dr. Sam Radhakrishnan, an interventional cardiologist. "Once they develop these symptoms, particularly the heart failure symptoms, unfortunately medications are solely palliative. They don't treat the underlying problem. And by not treating the underlying problem, the valve continues to narrow such that the heart is unable to cope and ultimately fails."

Mortality is upwards of 50 per cent in the first year for patients with critical aortic stenosis.

"That's worse than most cancers actually," Dr. Radhakrishnan says.

Ron visited a cardiac surgeon who advised him it would be too risky to operate on the valve in the traditional way: open-heart surgery.

But he told Ron of a new procedure being offered at Sunnybrook, where a team of cardiologists and surgeons could repair the valve without opening the chest.

During transcatheter aortic valve implantation (TAVI), a team of specialists, including a cardiologist, a cardiac surgeon and a vascular surgeon, accesses the body through an artery in the groin, or through a small incision under the collar bone or in the chest wall, and advances the valve to the heart.

"It was unbelievable, like snapping your fingers and feeling better," Ron says. "I immediately felt better. Before I even went for my follow-up appointment a month later, I was already going down to the gym in my condo and going on the bike."

Inside the catheterization lab, it takes a whole team to perform a TAVI.

"The exciting thing about the vascular team at Schulich is that we provide a service that I don't think you'll find anywhere else in Ontario and possibly in Canada: the endovascular work we do in the cath lab," Dr. Papia says. "When it comes to TAVI, the question is, 'Can you get to the vessels?' That's what Dr. Andrew Dueck and I do. We are the access guys in a sense."

Dr. Papia says that team approach is what sets the Schulich program apart from other heart centres.

"We really benefit from our combined knowledge sharing and skills," he says. "We pick the best procedure and we treat patients. We pick the best procedure for each patient."

Dr. Radhakrishan agrees.

"Our TAVI program is unique in Canada in that interventional cardiologists, cardiac surgeons and vascular surgeons are involved in the majority of cases. While it's fair to say that virtually all TAVI programs screen for eligible patients through multidisciplinary assessments, many still compartmentalize off the actual procedure to those that can be performed by interventional cardiologists alone or cardiac surgeons alone. That's not the approach we've taken, and frankly, I think we've been very successful, because it brings the collective expertise of the relevant Schulich Heart Centre specialists to the table for every patient.

"Our collaborative approach has enabled us to be on the leading edge of this remarkable and novel procedure in Canada."

"We fix the aneurysms through two small incisions in the groin in the main arteries of the leg," Dr. Papia explains. "We put up a series of wires and catheters, pre-ordered devices – off-the-shelf devices but custom designed, based on a unique software we have in our clinic."

Purchased by a generous donor, the software makes matching the size of the medical equipment to patients very accurate, Dr. Papia says.

"Just an example, we did six EVARs last week — none of them stayed past the weekend. They all went home within two days," Dr. Papia says. "Traditionally with a big, open operation, they have a one- to two-day ICU stay, a one-week hospital stay and a six-week recovery with a much higher complication rate. So this is just an unbelievable piece of technology."

With hundreds of EVARs successfully completed, Dr. Papia and Dr. Dueck are now setting their sights on advanced EVARs.

"These involve the vessels of the kidneys and the gastrointestinal organs. When aneurysms are involved there, the open procedure becomes much more high risk than the closed procedure," Dr. Papia said.

Using highly specialized custom grafts and planning out the procedure on the computer, the surgeons are able to take on cases turned down from other heart centres. Until recently, the procedure was funded entirely by donors. Thanks to the work done at Sunnybrook, it is now funded by the Ministry of Health.

Many minimally invasive procedures — for example, EVAR — are born when a Sunnybrook scientist or medical company invents a device that allows for a new way of doing a procedure. Then, staff becomes trained on the new procedure, and the surgeons, imaging scientists and researchers all then work together to perfect its delivery. Sunnybrook Foundation raises money to fund it so enough procedures can be performed to show the Ministry of Health it works, and works well.

So, Dr. Strauss says, Schulich's experts have to know what's going on in terms of the latest technology.

"We have to be at the table when the new technology comes out, and make sure we have access to it," he says.

What does the future hold?

While most minimally invasive valve procedures are presently reserved for high-risk patients, Dr. Radhakrishnan thinks that will change in the near future.

"In five to 10 years, we'll see these minimally invasive techniques used on a larger subset of patients for their cardiac disorders," Dr. Radhakrishnan says. "Certainly the skill sets of the operators and the technology will evolve and improve. And, equally important, the detailed non-invasive imaging needed to allow for further advances in these therapies will also improve."

Advances in imaging play a huge role, Dr. Strauss says.

"We have Dr. Graham Wright, who is the director of research for the Schulich Heart Program and he is an imaging scientist," Dr. Strauss says. "He understands how imaging contributes to the planning and the carrying out of the procedure. He's been very involved in trying to develop new imaging techniques, especially with MRI, to help us move forward."

Inventing and perfecting minimally invasive procedures is a natural fit for Sunnybrook, he says.

"I wish we just had more hours in the day," Dr. Strauss says. "That way, we could develop all the stuff that we could because we have everything here to make ourselves an incredible place of innovation."

But for patients like Steve Segal and Ron Armstrong, Sunnybrook is already a place of innovation.

"They gave me a new lease on life," Ron says. "The older we get, the more risky open surgeries are. But the team at Sunnybrook explained it all to me and I wasn't nervous at all. Now, I walk a couple miles a day. I golf. I'm really thankful."

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